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Fibroepithelial polyp of renal pelvis
FIBROEPITHELIAL POLYP OF RENAL PELVIS CLAUDE D. WOLGEL, M.D. ANTHONY C. PARRIS, M.D. HAROLD A. MITrY, M.D. HANS E. SCHAPIRA, M.D. From the Departments of Urology, Radiology, and Pathology, Mount Sinai Medical Center, New York, New York
ABSTRACT - - Primary mesodermal tumors of the renal pelvis are rare. Herein, the eighth case of fibroepithelial polyp of the renal pelvis is reported, this occurring in a nonfunctioning kidney. The diagnosis and treatment of fibroepithelial polyp is discussed and the literature reviewed.
Benign nonepithelial tumors of the renal pelvis are rare. While there are numerous reports of fibroepithelial polyps occurring in the ureter, 1 there are only 7 reported cases of fibroepithelial polyps (fibrous polyp, fibroma) of the renal pelvis in the literature. ~-8 Herein we report the eighth case of fibroepithelial polyp of the renal pelvis and review the literature. Case Report A thirty-six-year-old white woman was admitted to Mt. Sinai Hospital with a history of recurrent urinary tract infection resistant to antibiotics. The patient had been in good health until approximately eight months prior to admission when she noted the onset of dysuria, frequency, nocturia, and cloudy urine. She denied fever or flank tenderness. Repeated urine cultures were sterile. The symptoms abated with the use of antibiotics such as ampicillin and trimethoprim-sulfamethoxazole, but returned repeatedly shortly after the drugs were stopped. Her past medical history was unremarkable except for several months' exposure to a patient with tuberculosis. One sister had a history of calcium oxalate calculi. On admission the physical examination revealed no abnormalities. Appropriate laboratory studies were performed. The complete
436
blood count and blood chemistries were normal. The urine pH was 8. There were 0 to 3 white and 3 to 7 red blood cells per high-power field. Triple phosphate crystals and bacteria were noted. Chest x-ray film was normal. A Mantoux tuberculin skin test (P.P.D.) was strongly positive, and urine culture yielded Proteus mirabilis sensitive to ampicillin. Excretory urography (IVP) showed a radiopaque calculus in the left renal pelvis extending into the lower calyx with calicectasis (Fig. 1A). There was nonvisualization of the right kidney. Cystoscopy and bilateral retrograde pyelography were performed. The bladder appeared to be chronically inflamed with severe e r y t h e m a and floating debris. The right and left ureters were catheterized, and urine specimens for culture and sensitivity and acid-fast bacilli were taken from the left kidney and bladder. No urine was obtainable from the right kidney. The retrograde pyelogram findings on the left were essentially unchanged from the IVP with the addition of some irregularity of the upper ureter (Fig. 1B). The right retrograde study showed a small kidney with calicectasis. There was a multilobular filling defect occupying most of the lower calyceal system and a good portion of the renal pelvis. No associated contour defect in the collecting system was noted. Arteriography revealed a contracted right kidney with diffusely
UROLOGY
/
APRIL 1982
/
V O L U M E XIX, N U M B E R 4
FIGURE 1. IVP shows nonfunctioning right kidney and left kidney with pelvic calculus and pyelocalicectasis. (B) Retrograde pyelogram shows multilobular filling defect of right renal pelvis and lower calyceal system. (C) Right renal arteriogram shows contracted kidney with diffusely pruned vasculature.
was magnesium ammonium phosphate. Postoperatively the patient did well and was discharged' on the ninth day on a r e g i m e n of ampicillin. Pathology
FIGURE 2. Gross specimen reveals exophytic mass of right renal pelvis with gelatinous finger-like projections.
pruned vasculature (Fig. 1C). No tumor vessels were present. A tuberculosis workup was undertaken which included sputum samples and gastric washings for acid-fast bacilli along with morning urine specimens for culture, smear, and guinea pig inoculation. The patient was discharged and placed on a daily regimen of oral pyridoxin 100 mg., isoniazid (INH) 300 mg., and ethambutol 800 mg. along with ampicillin 500 mg. for a period of three weeks both as treatment and pending the laboratory results. Final report of all cultures was negative for tuberculosis. The patient was readmitted and underwent a right nephrectomy and left pyelolithotomy, both through flank incisions during the same anesthesia. A large calculus was removed from the left pelvis which on analysis
UROLOGY
/
APRIL 1962
/
V O L U M E XIX, N U M B E R 4
On removal, the right kidney was found to be atrophic and showed extensive hydronephrosis. Incision of the pelvis revealed a broad-based exophytic mass (Fig. 2). Its base measured 2 cm. in d i a m e t e r and involved the inferior portion of the renal pelvis proximal to the ureteropelvic junction and part of the inferior major calyx. From this base originated multiple finger-like projections that were gelatinous in consistency and protruded into the inferior and middle minor calyces. They measured 1 cm. in diameter, and their shape corresponded to that of the minor calyx into which they projected. The ureteral lumen was patent and the ureter unremarkable. Microscopic examination revealed the polypoidal mass consisted mostly of edematous fibrovascular tissue (Fig. 3). Its surface was covered with attenuated but otherwise normal transitional e p i t h e l i u m . Multiple nests of urothelial cells were noted within the stroma of the polyp. No atypical transitional cell foci were noted. Foci of chronic inflammatory cells were present throughout the lesion. A small area of calcification was present at the base of the polyp. The renal parenchyma showed severe atrophy, extensive chronic inflammatory cell infiltration of the interstitium, and glomeruli in various stages of sclerosis.
437
TABLE I. Reported fibroepithelial polyps of renal pelvis Series
Date
Sex, Age
Side
Presentation
Operative Procedure
Boross and Puhr 2
1929
F,29
Rt.
Nephrectomy and partial ureterectomy
Husch 3 Immergutt and Cottler4 Evans and Stevens 5 Shucksmith e
1949 1951
F,47 F,32
Lt. Rt.
1961
M,4
Rt.
Abdominal mass, fever, flank pain, frequency, cloudy urine Loin pain Flank pain, hematuria, frequency Flank pain
1963
M,60
Rt.
Hematuria, loin discomfort
Bernier et al. r
1970
F,42
Rt.
Dysuria, hematuria
Casimallys
1971
F,29
Rt.
Wolgel et al.
1981
F,36
Rt.
Loin pain, hematuria Dysuria, frequency, nocturia
Diagnosis was fibroepithelial polyp of the renal pelvis showing focal chronic inflammation and ossification. Comment Primary mesodermal tumors of the renal pelvis are extremely rare. Among those described have been leiomyoma, neurilemmoma, and angioma. 9 A review of the literature reveals only 7 cases of fibroepithelial polyp (fibrous polyp, fibroma) of the renal pelvis prior to our
FIGURE 3. Microscopicsection shows fibrovascular myxoid stroma covered by attenuated transitional epithelium (hematoxylin and eosin, original magnification × 40).
438
Nephrectomy Nephrectomy and partial ureterectomy Pyelotomy, nephroureterectomy Local removal of tumor with part of pelvis wall Pyelotomy, tumor resected with pedicle electrocoagulation Nephroureterectomy Nephrectomy
case. 2-8 As shown in Table I, these tumors have a predilection for women over men (6:2) and were unilateral, with all but one occurring on the right side. The patients were commonly in their third and fourth decades. Hematuria and flank pain were common presenting complaints. Urinalyses varied showing red blood cells or both red and white blood cells. Urine cultures when reported were commonly sterile. Cytology, reported in only 1 case, revealed transitional cells with atypical nuclei. Excretory urography commonly showed evidence of obstruction with pyelectasis and/or calicectasis. In 3 cases there was nonvisualization of the affected side. Cystoscopy usually revealed normal bladder mucosa and normal contralateral orifice with either pus, blood, or clear efflux from the ipsilateral orifice. Retrograde pyelography was most helpful showing dilatation and filling defects in patients having this radiologic study. At operation nephroureterectomy was performed in 2 cases, nephrectomy with partial ureterectomy in 2, and nephrectomy in 2 of the 8 cases. A pyelotomy was utilized in 3 of 8 cases.5r One of these became a nephroureterectomy, while in the other 2 cases local removal of the tumor and pedicle with either fulguration or removal of part of the pelvic wall was performed. Postoperative course was reported as uneventful in all cases regardless of procedure.
UROLOGY
/
APRIL 1982 /
VOLUME XIX, NUMBER4
Comparison of this renal pelvic polyp with the much more common fibroma of the ureter reveals some interesting differences apart from the great disparity between numbers of reported cases. Ureteral polyps occur in men more often, with a male to female ratio of 3:2, and are more commonly found on the left side. Mean age is thirty-three years. 1 The origin of these tumors, like that of their malignant counterparts, is not well established. Some theorize that they may be secondary to infection or chronic irritation, perhaps as seen with polyps of the nasopharynx. However, most cases of ureteral fibromas, as was found in this review of pelvic fibromas, occur without demonstrable infection. A congenital origin or the possibility of the lesion being a primary neoplasm also has been postulated. 1,5,10 Concerning surgical treatment there have been pleas for conservatism by some in dealing with both the ureteral l°'is and the renal pelvic polyps. ~-7 Pyelotomy or ureterotomy and then, according to appearance and frozen section resuits, local resection of the tumor, pedicle, and pelvic wall or ureter has been advocated, However, in this review of the renal polyps the clinical, roentgenologic, and urologic features of this benign lesion commonly paralleled those of transitional cell carcinoma of the renal pelvis. In addition, there was often significant hydronephrotic damage to the involved kidney. From this study, if a woman in her third or fourth decade is seen with a filling defect of the right renal pelvis, one should consider the possibility of a fibroepithelial polyp, recognizing that the incidence of transitional cell carcinoma would be much higher. Treatment in each case must be individualized. Urine cytology and in
UROLOGY / APRIL 1962 / VOLUME XIX, NUMBER4
some cases brush biopsy and perhaps nephroscopy may be utilized. Although a pyelotomy with possible segmental resection may permit more accurate diagnosis, it must be remembered that this violates technique of closed cancer surgery and carries the risk of dissemination of tumor cells and of recurrence due to the multifocal nature of the disease. Nephroureterectomy with a bladder cuff must still be considered strongly unless clear evidence exists that the lesion is benign in nature. 47 E. 77th Street New York, New York 10021 (DR. SCHAPIRA) References 1. Stuppler SA, and Kandzari SJ: Fibroepithelial polyps of ureter, Urology 5:553 (1975). 2. Boross E, and Puhr L: Fibroma of renal pelvis, Orv. Hetil. 73:1055 (1929). 3. Husch P: r2ber einen fall yon myxom des nierenbeckens, Z. Urol. 42:286 (1949). 4. Immergnt S, and Cottler ZR: Intrapelvic fibroma, J. Urol. 66:673 (1951). 5. Evans AT, and Stevens RK: Fibroepithelial polyps of ureter and renal pelvis: a case report, ibid. 86:313 (1961). 6. Shucksmith HS: Fibroma of the renal pelvis, Br. J. Urol. 35:261 (1963). 7. Bernier L, Bedard A, and Narcisse R: Fibrome du bassinet, Canad. J. Surg. 13:315 (1970). 8. Cassimally KAI: Fibroma filling the renal pelvis: report of a ease, Canad. J. Surg. 14:350 (1971). 9. Bennington JL, and Beckwith JB: Tumors of kidney, renal pelvis and ureter, in: Atlas of Tumor Pathology, Washington, D.C., Armed Forces Institute of Pathology, 1975, 2nd series, fasc. 12, p. 312. 10. Crum PM, Sayegh ES, Sacher EC, and Wescott JW: Benign ureteral polyps, J. Urol. 102:678 (1959). 11. Vest SA: Conservative surgery in certain benign tumors of the ureter, ibid. 53:97 (1945). 12. DeKlotz RJ, and Young BW: Conservative surgery in the management of benign ureteral polyps, Br. J. Urol. 36:375 (1964). 13. Colgan JR, Skaist L, and Morrow JW: Benign ureteral polyps in childhood: a case report and a plea for conservative management, J. Urol. 109:308 (1973).
439
ABSTRACT - - Primary mesodermal tumors of the renal pelvis are rare. Herein, the eighth case of fibroepithelial polyp of the renal pelvis is reported, this occurring in a nonfunctioning kidney. The diagnosis and treatment of fibroepithelial polyp is discussed and the literature reviewed.
Benign nonepithelial tumors of the renal pelvis are rare. While there are numerous reports of fibroepithelial polyps occurring in the ureter, 1 there are only 7 reported cases of fibroepithelial polyps (fibrous polyp, fibroma) of the renal pelvis in the literature. ~-8 Herein we report the eighth case of fibroepithelial polyp of the renal pelvis and review the literature. Case Report A thirty-six-year-old white woman was admitted to Mt. Sinai Hospital with a history of recurrent urinary tract infection resistant to antibiotics. The patient had been in good health until approximately eight months prior to admission when she noted the onset of dysuria, frequency, nocturia, and cloudy urine. She denied fever or flank tenderness. Repeated urine cultures were sterile. The symptoms abated with the use of antibiotics such as ampicillin and trimethoprim-sulfamethoxazole, but returned repeatedly shortly after the drugs were stopped. Her past medical history was unremarkable except for several months' exposure to a patient with tuberculosis. One sister had a history of calcium oxalate calculi. On admission the physical examination revealed no abnormalities. Appropriate laboratory studies were performed. The complete
436
blood count and blood chemistries were normal. The urine pH was 8. There were 0 to 3 white and 3 to 7 red blood cells per high-power field. Triple phosphate crystals and bacteria were noted. Chest x-ray film was normal. A Mantoux tuberculin skin test (P.P.D.) was strongly positive, and urine culture yielded Proteus mirabilis sensitive to ampicillin. Excretory urography (IVP) showed a radiopaque calculus in the left renal pelvis extending into the lower calyx with calicectasis (Fig. 1A). There was nonvisualization of the right kidney. Cystoscopy and bilateral retrograde pyelography were performed. The bladder appeared to be chronically inflamed with severe e r y t h e m a and floating debris. The right and left ureters were catheterized, and urine specimens for culture and sensitivity and acid-fast bacilli were taken from the left kidney and bladder. No urine was obtainable from the right kidney. The retrograde pyelogram findings on the left were essentially unchanged from the IVP with the addition of some irregularity of the upper ureter (Fig. 1B). The right retrograde study showed a small kidney with calicectasis. There was a multilobular filling defect occupying most of the lower calyceal system and a good portion of the renal pelvis. No associated contour defect in the collecting system was noted. Arteriography revealed a contracted right kidney with diffusely
UROLOGY
/
APRIL 1982
/
V O L U M E XIX, N U M B E R 4
FIGURE 1. IVP shows nonfunctioning right kidney and left kidney with pelvic calculus and pyelocalicectasis. (B) Retrograde pyelogram shows multilobular filling defect of right renal pelvis and lower calyceal system. (C) Right renal arteriogram shows contracted kidney with diffusely pruned vasculature.
was magnesium ammonium phosphate. Postoperatively the patient did well and was discharged' on the ninth day on a r e g i m e n of ampicillin. Pathology
FIGURE 2. Gross specimen reveals exophytic mass of right renal pelvis with gelatinous finger-like projections.
pruned vasculature (Fig. 1C). No tumor vessels were present. A tuberculosis workup was undertaken which included sputum samples and gastric washings for acid-fast bacilli along with morning urine specimens for culture, smear, and guinea pig inoculation. The patient was discharged and placed on a daily regimen of oral pyridoxin 100 mg., isoniazid (INH) 300 mg., and ethambutol 800 mg. along with ampicillin 500 mg. for a period of three weeks both as treatment and pending the laboratory results. Final report of all cultures was negative for tuberculosis. The patient was readmitted and underwent a right nephrectomy and left pyelolithotomy, both through flank incisions during the same anesthesia. A large calculus was removed from the left pelvis which on analysis
UROLOGY
/
APRIL 1962
/
V O L U M E XIX, N U M B E R 4
On removal, the right kidney was found to be atrophic and showed extensive hydronephrosis. Incision of the pelvis revealed a broad-based exophytic mass (Fig. 2). Its base measured 2 cm. in d i a m e t e r and involved the inferior portion of the renal pelvis proximal to the ureteropelvic junction and part of the inferior major calyx. From this base originated multiple finger-like projections that were gelatinous in consistency and protruded into the inferior and middle minor calyces. They measured 1 cm. in diameter, and their shape corresponded to that of the minor calyx into which they projected. The ureteral lumen was patent and the ureter unremarkable. Microscopic examination revealed the polypoidal mass consisted mostly of edematous fibrovascular tissue (Fig. 3). Its surface was covered with attenuated but otherwise normal transitional e p i t h e l i u m . Multiple nests of urothelial cells were noted within the stroma of the polyp. No atypical transitional cell foci were noted. Foci of chronic inflammatory cells were present throughout the lesion. A small area of calcification was present at the base of the polyp. The renal parenchyma showed severe atrophy, extensive chronic inflammatory cell infiltration of the interstitium, and glomeruli in various stages of sclerosis.
437
TABLE I. Reported fibroepithelial polyps of renal pelvis Series
Date
Sex, Age
Side
Presentation
Operative Procedure
Boross and Puhr 2
1929
F,29
Rt.
Nephrectomy and partial ureterectomy
Husch 3 Immergutt and Cottler4 Evans and Stevens 5 Shucksmith e
1949 1951
F,47 F,32
Lt. Rt.
1961
M,4
Rt.
Abdominal mass, fever, flank pain, frequency, cloudy urine Loin pain Flank pain, hematuria, frequency Flank pain
1963
M,60
Rt.
Hematuria, loin discomfort
Bernier et al. r
1970
F,42
Rt.
Dysuria, hematuria
Casimallys
1971
F,29
Rt.
Wolgel et al.
1981
F,36
Rt.
Loin pain, hematuria Dysuria, frequency, nocturia
Diagnosis was fibroepithelial polyp of the renal pelvis showing focal chronic inflammation and ossification. Comment Primary mesodermal tumors of the renal pelvis are extremely rare. Among those described have been leiomyoma, neurilemmoma, and angioma. 9 A review of the literature reveals only 7 cases of fibroepithelial polyp (fibrous polyp, fibroma) of the renal pelvis prior to our
FIGURE 3. Microscopicsection shows fibrovascular myxoid stroma covered by attenuated transitional epithelium (hematoxylin and eosin, original magnification × 40).
438
Nephrectomy Nephrectomy and partial ureterectomy Pyelotomy, nephroureterectomy Local removal of tumor with part of pelvis wall Pyelotomy, tumor resected with pedicle electrocoagulation Nephroureterectomy Nephrectomy
case. 2-8 As shown in Table I, these tumors have a predilection for women over men (6:2) and were unilateral, with all but one occurring on the right side. The patients were commonly in their third and fourth decades. Hematuria and flank pain were common presenting complaints. Urinalyses varied showing red blood cells or both red and white blood cells. Urine cultures when reported were commonly sterile. Cytology, reported in only 1 case, revealed transitional cells with atypical nuclei. Excretory urography commonly showed evidence of obstruction with pyelectasis and/or calicectasis. In 3 cases there was nonvisualization of the affected side. Cystoscopy usually revealed normal bladder mucosa and normal contralateral orifice with either pus, blood, or clear efflux from the ipsilateral orifice. Retrograde pyelography was most helpful showing dilatation and filling defects in patients having this radiologic study. At operation nephroureterectomy was performed in 2 cases, nephrectomy with partial ureterectomy in 2, and nephrectomy in 2 of the 8 cases. A pyelotomy was utilized in 3 of 8 cases.5r One of these became a nephroureterectomy, while in the other 2 cases local removal of the tumor and pedicle with either fulguration or removal of part of the pelvic wall was performed. Postoperative course was reported as uneventful in all cases regardless of procedure.
UROLOGY
/
APRIL 1982 /
VOLUME XIX, NUMBER4
Comparison of this renal pelvic polyp with the much more common fibroma of the ureter reveals some interesting differences apart from the great disparity between numbers of reported cases. Ureteral polyps occur in men more often, with a male to female ratio of 3:2, and are more commonly found on the left side. Mean age is thirty-three years. 1 The origin of these tumors, like that of their malignant counterparts, is not well established. Some theorize that they may be secondary to infection or chronic irritation, perhaps as seen with polyps of the nasopharynx. However, most cases of ureteral fibromas, as was found in this review of pelvic fibromas, occur without demonstrable infection. A congenital origin or the possibility of the lesion being a primary neoplasm also has been postulated. 1,5,10 Concerning surgical treatment there have been pleas for conservatism by some in dealing with both the ureteral l°'is and the renal pelvic polyps. ~-7 Pyelotomy or ureterotomy and then, according to appearance and frozen section resuits, local resection of the tumor, pedicle, and pelvic wall or ureter has been advocated, However, in this review of the renal polyps the clinical, roentgenologic, and urologic features of this benign lesion commonly paralleled those of transitional cell carcinoma of the renal pelvis. In addition, there was often significant hydronephrotic damage to the involved kidney. From this study, if a woman in her third or fourth decade is seen with a filling defect of the right renal pelvis, one should consider the possibility of a fibroepithelial polyp, recognizing that the incidence of transitional cell carcinoma would be much higher. Treatment in each case must be individualized. Urine cytology and in
UROLOGY / APRIL 1962 / VOLUME XIX, NUMBER4
some cases brush biopsy and perhaps nephroscopy may be utilized. Although a pyelotomy with possible segmental resection may permit more accurate diagnosis, it must be remembered that this violates technique of closed cancer surgery and carries the risk of dissemination of tumor cells and of recurrence due to the multifocal nature of the disease. Nephroureterectomy with a bladder cuff must still be considered strongly unless clear evidence exists that the lesion is benign in nature. 47 E. 77th Street New York, New York 10021 (DR. SCHAPIRA) References 1. Stuppler SA, and Kandzari SJ: Fibroepithelial polyps of ureter, Urology 5:553 (1975). 2. Boross E, and Puhr L: Fibroma of renal pelvis, Orv. Hetil. 73:1055 (1929). 3. Husch P: r2ber einen fall yon myxom des nierenbeckens, Z. Urol. 42:286 (1949). 4. Immergnt S, and Cottler ZR: Intrapelvic fibroma, J. Urol. 66:673 (1951). 5. Evans AT, and Stevens RK: Fibroepithelial polyps of ureter and renal pelvis: a case report, ibid. 86:313 (1961). 6. Shucksmith HS: Fibroma of the renal pelvis, Br. J. Urol. 35:261 (1963). 7. Bernier L, Bedard A, and Narcisse R: Fibrome du bassinet, Canad. J. Surg. 13:315 (1970). 8. Cassimally KAI: Fibroma filling the renal pelvis: report of a ease, Canad. J. Surg. 14:350 (1971). 9. Bennington JL, and Beckwith JB: Tumors of kidney, renal pelvis and ureter, in: Atlas of Tumor Pathology, Washington, D.C., Armed Forces Institute of Pathology, 1975, 2nd series, fasc. 12, p. 312. 10. Crum PM, Sayegh ES, Sacher EC, and Wescott JW: Benign ureteral polyps, J. Urol. 102:678 (1959). 11. Vest SA: Conservative surgery in certain benign tumors of the ureter, ibid. 53:97 (1945). 12. DeKlotz RJ, and Young BW: Conservative surgery in the management of benign ureteral polyps, Br. J. Urol. 36:375 (1964). 13. Colgan JR, Skaist L, and Morrow JW: Benign ureteral polyps in childhood: a case report and a plea for conservative management, J. Urol. 109:308 (1973).
439